Discussion
Hiatal hernia may be transient or permanent and cause the stomach to pass through the diaphragm and enter the chest. Surgical intervention, including hernia reduction, closure of the esophageal hiatus, and anti-reflux procedure, may be necessary for types II, III, and IV hernias with severe esophagitis. It may also involve other abdominal organs, as observed in the present case. The most common organs associated with the stomach are the colon, small intestine and omentum. A giant hiatal hernia has been reported frequently; however, cases of giant hernia with pancreatic prolapse is extremely rare [4]. Stretching of the transverse mesocolon has been reported to increase the mobility of the pancreas owing to greater relaxation of the posterior adherent fascia. A recent study of a human cadaver reported a posterior pancreatic fascia covering the posterior surface of the main body of pancreas but was unable to locate the anterior renal fascia, possibly because of age-related degeneration of the adrenal glands [5]. In the elderly, the pancreas may be more mobile owing to connective tissue degeneration, making it more likely to migrate from a hiatal hernia. Pancreatic hernias are asymptomatic [6] [7], and most cases are discovered incidentally during CT scans performed to evaluate features characteristic of giant esophageal hernias, such as abdominal pain [8] [9], vomiting [10] [11], dysphagia [3], and dyspnea [12]. In this case, the patient complained of dysphagia and was found to have a giant hiatal hernia with pancreatic prolapse. However, there are no reports of neoplastic lesions in the prolapsed pancreas. In this case, the pancreas with a tumor requiring resection had prolapsed into the posterior mediastinum due to a giant hiatal hernia. We performed hiatal hernia surgery before pancreatic resection to ensure that a safe pancreatic resection is conducted. Preceding hiatal hernia repair allows pancreatic resection to be performed in the normal anatomical position, thereby increasing safety of the procedure. One study reported a case of pancreatitis and bile duct dilatation secondary to a giant hiatal hernia of the pancreatic tail [13]. Therefore, pancreatic resection without esophageal hiatal hernia repair in the present case may pose a risk of inflammation extending into the mediastinum when complications, such as pancreatic fistula, develop.